Form Ds-875y - Article 19-A Oral/written Examination Results
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1ARTICLE 19-A ORAL/WRITTEN EXAMINATION RESULTS
dmv.ny.gov
INSTRUCTIONS TO CERTIFIED EXAMINER
After administering the exam, and using the answer key provided (form DS-875Z, “Article 19-A Written Examination
Answer Sheet”), complete this form and attach it to the driver’s completed examination. Keep all paperwork in the
driver’s 19-A file.
TYPE OF EXAMINATION
o
o
o
Oral
Written
Re-examination
DRIVER INFORMATION
Driver’s Last Name
First
M.I.
Date of Birth (Month/Day/Year)
Driver License ID Number
State Licensed
License Class Endorsements
Restrictions
Expiration Date
Driver’s Signature
CARRIER INFORMATION
Carrier/DBA Name
Legal Name (if different)
Federal ID Number
19-A Business ID Number
DRIVER EXAMINATION RESULTS
Number of Questions Correctly Answered
o
SECTION A
SECTION B
Passed
15
5
EXAMINER’S CERTIFICATION
Driver License ID Number
Certified Examiner’s Name
Certificate Number
Certification Class
Endorsements
Restrictions
Expiration Date
CERTIFICATION: I certify that I currently hold a valid examiner certification as required in accordance with Article 19-A of the New
York State Vehicle and Traffic Law, that I have tested the above driver in compliance with Section 6.12 and/or Section 6.15 of Part 6
of the Commissioner’s Regulations and reported the results to the employer. I acknowledge and understand that knowingly making
a false statement in connection with this report or in any proofs or reports in connection with it for the purpose of deceiving or
substituting, or causing another person to deceive or substitute, in connection with this examination or report may subject me to
criminal prosecution for a misdemeanor or felony under the Vehicle and Traffic Law and/or Penal Law.
Certified Examiner’s Signature
Date of Examination
-
reset/clear
DS-875Y (9/16)
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